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Nursing Issues in Pediatric CRRT

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Do not infuse other medications or blood products directly into the CRRT system ... Exit site s/s redness, drainage, crusting, swelling, odor, or pain ... – PowerPoint PPT presentation

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Title: Nursing Issues in Pediatric CRRT


1
Nursing Issues in Pediatric CRRT
  • Helen Currier BSN, RN, CNN
  • Assistant Director Renal, Pheresis
  • Scholar Center for Clinical Research

2
CRRT Treatment ResponsibilitiesPoints to
Remember
  • Nephrology Nurse
  • Initiate treatment based on individual patient
    needs as assessed by the nephrologist
  • Bedside Nurse
  • Do not infuse other medications or blood products
    directly into the CRRT system
  • Cooling effects of CRRT may prevent temperature
    elevation
  • Adjust patient fluid removal rate hourly to
    maintain net UFR
  • Changes in net URF

3
Before TreatmentEquipment/Supplies
  • Nephrology Nurse
  • Prisma/Prisma tubing
  • Bedside Nurse
  • Order dialysis fluid citrate and any replacement
    solutions
  • IV tubing for each infusion pump
  • 3-way stopcocks
  • Extracorporeal circuit warmer
  • Extracorporeal circuit prime
  • Telephone at bedside

4
Before TreatmentEquipment/Supplies
  • Nephrology Nurse
  • Review and note CRRT orders
  • Verify consent
  • Notify bedside nurse of treatment orders and
    initiation time
  • Set-up and prime CRRT circuit with heparinized
    normal saline
  • Prime other lines in CRRT circuit
  • Verify catheter placement
  • Bedside Nurse
  • Review, clarify, and note CRRT
  • Draw baseline labs per CRRT orders
  • Explain procedure and answer questions as needed
  • Check cannulated limb for circulation

5
Catheter Issues
  • Design largest diameter w/shortest length
  • Diameter
  • 19 ? flow 2x
  • 50 ? flow 5x
  • Increasing from 2.0mm to 2.1 mm increases flow
    21
  • Length
  • 19 ? in diameter will compensate for doubling of
    length
  • Placement
  • Site RIJ (LIJ, IVC, Subclavian)
  • Tip well within the atrium

6
Catheter Issues
  • Catheter flow
  • Early malposition
  • Kink
  • Tip malposition too high/low
  • Tip malposition arterial against the wall
  • Tight suture
  • Tip in wrong vessel
  • Late thrombosis or fibrin sheath formation

7
Catheter Issues
  • Catheter related infection
  • Local
  • Exit site s/s redness, drainage, crusting,
    swelling, odor, or pain
  • Tunnel s/s swelling, pain, redness or ability
    to express draining down the tunnel track to the
    exit site
  • Systemic
  • Catheter related bacteremia

8
Treatment Initiation
  • Nephrology Nurse
  • Assess patients condition fluid and electrolyte
  • Prep catheter ports
  • Aspirate appropriate blood volume from catheter
    and flush w/saline
  • Prime CRRT circuit w/priming solution and attach
    blood lines of equipment to catheter(s)
  • Start citrate drip
  • After 5 w/stable VS, start replacement fluid and
    ultrafiltration
  • Change catheter site dressing if needed
  • Bedside Nurse
  • Assess patients condition fluid and electrolyte
  • Baseline VS, Wt, PAWP (if applicable), CVP, BP,
    edema, lung/heart sounds, lab values
  • VS q 30 x 2 then q 1 h
  • Monitor and document starting AP, VP, DFR, RFR,
    BFR, URF and infusion pump rates

9
Nephrology Nurse
  • How CRRT works
  • Reason for treatment
  • When and how to terminate treatment
  • Equipment operation
  • Most common alarms
  • When and how to reach the nephrology team
  • Fluid balance calculations
  • Assessment of clotting
  • How to adjust AP/VP limits, BFR, or UFR
  • How to verify dialysis fluid or replacement fluid
    and/or rate changes

10
Bedside Nurse Competencies
  • Verbalize
  • How CRRT works (fluid and solute balance, changes
    in nutrition and medications)
  • Reason for treatment
  • When and how to terminate treatment
  • How to troubleshoot alarms (AP, VP, blood leak,
    error codes, air detector)
  • When and how to recirculate the system
  • How to care for catheter and catheter exit site
  • When and how to contact nephrologist or
    nephrology nurse
  • How to operate extracorporeal circuit warmer

11
Bedside Nurse Competencies
  • Demonstrate
  • How to calculate fluid balance
  • How to assess clotting in the system
  • How to adjust AP and VP limits, BFR, UFR
  • How to verify dialysis and replacement fluid
    solution and rates
  • Document continuing care in nursing notes and
    flow sheet

12
CRRT Treatment Responsibilitiesq 1 hour
  • Bedside Nurse
  • Monitor system for kinks, loose connections,
    patient bleeding
  • Evaluate changes in pressure reading VP or AP
  • Evaluate hemofilter and venous chamber for
    clotting or fibrin
  • Evaluate color of ultrafiltrate (no pink-tinged
    fluid)
  • Document arterial pressure (AP), venous pressure,
    BFR, and intake/output

13
CRRT Treatment Responsibilitiesq 2 hr into
treatment/ q 6 hr thereafter
  • Bedside Nurse
  • Check circuit ionized Ca (sample from venous
    port) and patients ionized Ca (sample from
    site other than CRRT circuit)
  • Recheck CRRT circuit/patient ionized Ca after
    any changes in anticoagulation reference
    optimal ranges specified
  • Notify nephrology nurse if circuit clots

14
CRRT Treatment Responsibilitiesq 24 hr
  • Bedside Nurse
  • Assess patients fluid/electrolyte balance and
    overall condition, PAWP (if applicable), CVP,
    edema, lungs, heart
  • Evaluate serum chemistry for changes
  • Monitor serum calcium and pH for signs of citrate
    toxicity
  • Monitor for s/s of sepsis or local infection
  • Monitor for s/s of hypothermia
  • Assess and monitor patients nutritional status
    daily weight, albumin, bowel patterns, skin
    turgor, muscle wasting
  • Monitor the integrity of the access dressing
    change per protocol

15
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16
Potential Complications with Pediatric
Hemofiltration
  • Circuit Volumes
  • Hypothermia
  • Anticoagulation
  • Fluid Management
  • Blood Flow Rates
  • Nutrition
  • Solutions

17
Circuit Volumes
  • Significant when dealing with pediatrics
  • General Guidelines
  • Circuit volumes should be lt 10 of the patients
    intravascular blood volume

18
Blood Priming
  • Indications
  • Circuit volume gt 10 of the patients blood volume
  • Hemodynamic instability
  • Infants

19
Complications of Blood Priming
  • Blood Bank pRBC tend to be high in K
  • Close K monitoring needed at initiation
  • pRBC HCT are approximately 80
  • 11 dilution with normal saline
  • Blood prime need to be done at time of
    initiation.
  • Citrate binds calcium
  • hypotension

20
Hypothermia
  • Significant in pediatrics
  • The smaller the more difficult
  • Heat loss related to rate of blood flow and
    volume of blood in circuit
  • Blood flow rate
  • Higher blood flow rate decrease heat loss due to
    less time outside of the body

21
Hypothermia Nursing intervention
  • External warming devices
  • Radiant warmers
  • Baer hugger
  • Heating mattress
  • Blood warmers
  • Solutions heaters
  • Monitoring
  • Skin breakdown and patient temperature

22
Anticoagulation
  • Nursing assessment
  • Monitor ACT q 1-2 hours
  • via Hemochron
  • Maintain ACT range 150-200
  • Monitor for active bleeding
  • Monitor circuit for cracks and clotting

23
Fluid Management
  • Ultrafiltration controller necessary
  • Pumps up to 30 inaccurate
  • Ultrafiltration rate 0.5-1ml/kg/hr
  • Difficulty in accurate assessment of measurement
    of u/f with less room for error in small children

24
Fluid ManagementNursing
  • Accurate Intake and Output assessments
  • Hourly ultrafiltration calculations
  • Monitoring vital signs
  • Heart Rate, CVP, Blood pressures
  • Patient Weights
  • q 12 hours or daily
  • IMPORTANT - Look at your patient

25
Access Difficulties
  • What is the correct access?
  • ? Best placement
  • In flow vs out flow difficulties

26
In Flow Difficulties
  • Obstruction or clot upstream of inflow
  • high intrathoracic pressure with HIFI
  • up against the vessel wall
  • Clamp on inflow
  • Access kinked at skin site
  • Consider reversing or changing access

27
Out Flow Difficulties
  • Clamp on access/arterial line
  • Inflow port up against vessel wall
  • Patient dry e.g. with femoral site
  • High of blood flow requirements based upon flow
    ability of access
  • Consider
  • reverse flow, change access, decrease blood flow
    rates
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